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NIHR Signal Patient-centred care for multimorbidity improves patient experience, but quality of life is unchanged

A patient-centred intervention in general practice for people with multiple chronic conditions, based on recommended best practice, had no effect on patient quality of life or burden of illness and treatment. Patients were, however, more likely to report being satisfied with their care.

An increasing number of people in the UK are living with multimorbidity, defined as two or more long-term health conditions. NICE recommends a comprehensive approach to care, tailored to the patient’s needs. This NIHR-funded trial conducted in 33 general practices in England and Scotland, is the largest to assess these care principles for multimorbidity.

Practices were assigned to perform patient reviews by a nurse, GP and pharmacist every six months, assessing health, depression and medications, or continue with usual care. Health and treatment outcomes were no different at 15 months.

However, patients valued having personalised care plans and the opportunity to discuss their concerns, and there may be long-term benefits. A cost analysis is awaited, which could inform whether these alone are sufficient benefits.

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Why was this study needed?

The UK has an ageing population. A 2018 study of multimorbidity in England found that 54% of people aged over 65 years had multimorbidity in 2015. This is expected to rise to 68% by 2035, with 17% of people over 65 years expected to have four or more conditions.

National guidelines tend to focus on single conditions. People with multimorbidity may have their conditions managed individually without due consideration of the overall burden of their diseases and treatments. Recognition of this prompted NICE and other international organisations to develop guidelines on management of multimorbidity, which focus on regular comprehensive review of the person’s health and circumstances.

But there is uncertainty over the best approach. A 2016 Cochrane review found that trials had assessed diverse patient-centred interventions in primary care, with mixed findings. This trial assessed a care model that incorporated all strategies recommended by guidelines.

What did this study do?

This cluster-randomised controlled trial allocated 33 general practices in England and Scotland to provide comprehensive, three-dimensional reviews of multimorbidity or to continue with usual care. Medical records were used to identify adults with at least three of 17 chronic conditions listed in the Quality and Outcomes Framework (QOF). A total of 1,546 participants were included (average 71 years).

Three-dimensional reviews were conducted six-monthly. It included a nurse appointment to discuss the patient’s key health concerns, effects on daily life and to screen for depression and dementia. A pharmacist reviewed their medications. The patient then met with their doctor who considered the reviews from the nurse and pharmacist and agreed a health plan, including realistic goals with the patient.

Two-thirds of people eligible for the study declined or did not respond to the invitation, which could affect representation. Only 49% of participants in intervention practices received two reviews as intended.

What did it find?

The multimorbidity review had no effect on quality of life at 15 months. There was 0.00 difference in EQ-5D-5L quality of life score between groups (95% confidence interval [CI] −0.02 to +0.02) following adjustment for baseline variables, practice location and list size.

There was no difference in any measure of illness burden, which included self-rated health, anxiety and depression scores, or in measures of treatment burden, which included number of drugs prescribed and medication adherence.

Patients having the multimorbidity review, did, however, have better patient-centred care than those receiving usual care. This included higher Patient Assessment of Care for Chronic Conditions scores which range from 1 to 5 (adjusted mean difference 0.29, 96% CI 0.16 to 0.41), and greater proportions of participants reporting being very satisfied with care (56% vs 39%) and having the opportunity to discuss problems of greatest importance to them (42% vs 26%).

Measures of process of care at 15 months showed mixed results. Multimorbidity review increased the number of GP consultations to 10 compared with 8 (adjusted mean 1.13, 95% CI 1.02 to 1.25), nurse consultations to 6 compared with 4 (1.37, 95% CI 1.17 to 1.61) and gave greater continuity of care (adjusted difference +0.08, 95% CI 0.02 to 0.13 on an index ranged from 0 [none] to 1 [perfect continuity]). However, it had no effect on the number of QOF indicators met, number of indicators of high prescribing, number of hospital admissions or outpatient appointments.

What does current guidance say on this issue?

NICE’s 2016 guideline on clinical assessment and management of multimorbidity provides guidance on identifying patients with multimorbidity. It recommends establishing the patient’s burden of disease and treatment, their values and priorities, reviewing medications, and agreeing an individualised management plan. The central aim of this approach is to allow patients to actively participate in their care, ensure services meet their needs, improve continuity of care and relationships, and ultimately improve the patient’s quality of life.

However, there is no recommendation on how often multimorbidity reviews should be carried out.

What are the implications?

Comprehensive care reviews for multimorbidity appear to improve patients' experience of care but have no effect on quality of life. It may be because the intervention was not delivered at full dose/intensity (only 49% received the full two sessions) or monitored for long enough. However, the results are in line with other large trials included in a recently updated Cochrane review.

The principles of care in the control group are generally consistent with NICE guidelines. Yet there is likely to be variation across trusts and practices in the specifics of how QOF reviews are conducted and how frequently. The forthcoming analysis will inform how cost-effective this six-monthly three-dimensional approach was in terms of the improvement in patient satisfaction.

Why was this study needed?

The UK has an ageing population. A 2018 study of multimorbidity in England found that 54% of people aged over 65 years had multimorbidity in 2015. This is expected to rise to 68% by 2035, with 17% of people over 65 years expected to have four or more conditions.

National guidelines tend to focus on single conditions. People with multimorbidity may have their conditions managed individually without due consideration of the overall burden of their diseases and treatments. Recognition of this prompted NICE and other international organisations to develop guidelines on management of multimorbidity, which focus on regular comprehensive review of the person’s health and circumstances.

But there is uncertainty over the best approach. A 2016 Cochrane review found that trials had assessed diverse patient-centred interventions in primary care, with mixed findings. This trial assessed a care model that incorporated all strategies recommended by guidelines.

What did this study do?

This cluster-randomised controlled trial allocated 33 general practices in England and Scotland to provide comprehensive, three-dimensional reviews of multimorbidity or to continue with usual care. Medical records were used to identify adults with at least three of 17 chronic conditions listed in the Quality and Outcomes Framework (QOF). A total of 1,546 participants were included (average 71 years).

Three-dimensional reviews were conducted six-monthly. It included a nurse appointment to discuss the patient’s key health concerns, effects on daily life and to screen for depression and dementia. A pharmacist reviewed their medications. The patient then met with their doctor who considered the reviews from the nurse and pharmacist and agreed a health plan, including realistic goals with the patient.

Two-thirds of people eligible for the study declined or did not respond to the invitation, which could affect representation. Only 49% of participants in intervention practices received two reviews as intended.

What did it find?

The multimorbidity review had no effect on quality of life at 15 months. There was 0.00 difference in EQ-5D-5L quality of life score between groups (95% confidence interval [CI] −0.02 to +0.02) following adjustment for baseline variables, practice location and list size.

There was no difference in any measure of illness burden, which included self-rated health, anxiety and depression scores, or in measures of treatment burden, which included number of drugs prescribed and medication adherence.

Patients having the multimorbidity review, did, however, have better patient-centred care than those receiving usual care. This included higher Patient Assessment of Care for Chronic Conditions scores which range from 1 to 5 (adjusted mean difference 0.29, 96% CI 0.16 to 0.41), and greater proportions of participants reporting being very satisfied with care (56% vs 39%) and having the opportunity to discuss problems of greatest importance to them (42% vs 26%).

Measures of process of care at 15 months showed mixed results. Multimorbidity review increased the number of GP consultations to 10 compared with 8 (adjusted mean 1.13, 95% CI 1.02 to 1.25), nurse consultations to 6 compared with 4 (1.37, 95% CI 1.17 to 1.61) and gave greater continuity of care (adjusted difference +0.08, 95% CI 0.02 to 0.13 on an index ranged from 0 [none] to 1 [perfect continuity]). However, it had no effect on the number of QOF indicators met, number of indicators of high prescribing, number of hospital admissions or outpatient appointments.

What does current guidance say on this issue?

NICE’s 2016 guideline on clinical assessment and management of multimorbidity provides guidance on identifying patients with multimorbidity. It recommends establishing the patient’s burden of disease and treatment, their values and priorities, reviewing medications, and agreeing an individualised management plan. The central aim of this approach is to allow patients to actively participate in their care, ensure services meet their needs, improve continuity of care and relationships, and ultimately improve the patient’s quality of life.

However, there is no recommendation on how often multimorbidity reviews should be carried out.

What are the implications?

Comprehensive care reviews for multimorbidity appear to improve patients' experience of care but have no effect on quality of life. It may be because the intervention was not delivered at full dose/intensity (only 49% received the full two sessions) or monitored for long enough. However, the results are in line with other large trials included in a recently updated Cochrane review.

The principles of care in the control group are generally consistent with NICE guidelines. Yet there is likely to be variation across trusts and practices in the specifics of how QOF reviews are conducted and how frequently. The forthcoming analysis will inform how cost-effective this six-monthly three-dimensional approach was in terms of the improvement in patient satisfaction.

Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach

Background
The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention.
Methods
We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months' follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958.
Findings
Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention.
Interpretation
To our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients' quality of life.
Funding
National Institute for Health Research.

Expert commentary

Improving the care of people with multimorbidity is a global priority, including for the United Kingdom’s NHS. People with multimorbidity generally have reduced quality of life, make greater use of health services and have poorer health outcomes than people without multimorbidity.

This randomised controlled trial showed that one of the approaches advocated to improve the care of these patients (the 3D approach) did not improve patients’ quality of life any more than usual care. It did though lead to more patient-centred care. The study illustrates the difficulty in improving the care of patients with complex health needs and confirms there are no ‘magic bullets’.

Azeem Majeed, Professor of Primary Care and Head of the Department of Primary Care & Public Health at Imperial College London

Expert commentary

Improving patient experience is one of the triple aims of healthcare. Multimorbidity is associated with reduced quality of life, impaired function, worse physical and mental health and increased mortality. The aim of this study was to see if replacing separate disease-focused reviews with a six-monthly, multiprofessional whole-person 3D review improved health-related quality of life.

This large study of 1,546 patients, from 33 GP practices, with three or more chronic diseases, found the answer is ‘no'. There was no significant difference between the disease-focused and patient-centred 3D groups in health-related quality of life at 15 months follow up.

In addition, there was no significant difference between the groups in doctor consultations, hospital admissions or out-patient attendance. There were, however, fewer nurse consultations in the 3D group.

In opposition to current thinking, reducing the number visits to the surgery does not improve quality of life.

Expert commentary

Salisbury and colleagues tested providing six-monthly doctor, nurse and pharmacist reviews, incorporating international consensus patient-centred strategies as an intervention to manage multi-morbidity. They found no difference in quality of life outcomes but higher satisfaction with encounters among patients. It is too soon to dismiss such practice efforts.

As noted by the authors the outcome measure and the length of the trial may not be sufficient when people have three or more chronic conditions. Perhaps too the intervention remains too medically oriented and more should be done to incorporate the community and patient components recommended in the Chronic Care Model they utilised.